Hello everyone. I’m mostly holding up and hope this finds you holding up too.

Recent weeks, but particularly this past one, have been like being in a foreign country while never entirely leaving the familiarity of home. I wonder if it’s been feeling disjointed like this to you.

When travel takes you to an entirely new place, you notice small differences that would normally escape your attention if you were still back home, things like the music that’s playing in the background, the odd rooflines you’re passing on the bus, or the kinds of shoes that people are wearing. With big things like a new language or culture telling you how far you’ve traveled, you can end up paying closer attention to the smaller differences too.

In an essay he wrote after bringing some of his American students to Ireland for the first time, Liam Heneghan noticed the power that tourists often bring to their observations.

A tourist generally has an eye for the things that, through repetitive familiarity, have become almost invisible to the resident… A tourist can [recognize] … the delicious strangeness of mundane things.

This past week, I’ve felt like a tourist in my suddenly strange country.

Of course, the larger changes and contrasts that shouted “Something new is afoot!” have been apparent for awhile now: how things have gotten quieter and slower, and how the promise of spring keeps contradicting the darker messengers on the news every day. But this kind of quiet and slow, when nearly everything but the march of nature has ground to a halt has, in its novelty, caused me to notice things that I either missed or took for granted as a local before. This week, it’s been surprisingly consoling and enabling to see my home country through a tourist’s wide eyes.

The first way that home had changed is how quiet the city has become. Tires skimming the streets, honking horns, helicopters over Route 1 and I-76, jets streaming towards the airport, sidewalk conversations, pedestrians on their phones, radio sounds—rap, R&B and talk shows mostly, delivery trucks, cars parking, home repairs, street repairs, neighbors coming and going, shouts from the high school’s baseball diamond, a track team running by, that ice cream truck beckoning 3d graders with its annoying song: these sounds that John Cage called the music of a city are no longer being offered in a continuous live stream, if they’re being offered up at all. Even the hourly bells from Penn Charter nearby have gone strangely quiet.

The sounds that survive are now framed by something like silence, as if puffs of snow had blanketed everything around them. For sure, it makes the sirens on rescue vehicles stand out even more, but it also delivers other bells, from that church in Germantown for example, the way they might have told an older city that it’s the middle of the day. Because kids are home from school, their laughing and talking excitedly gains my attention whenever it erupts. If I’m outside and close enough, I can hear the green light at the intersection of Fox and Midvale click. And like fleeing the urban glow can reveal the stars in a sky that’s suddenly gone dark, the bird songs and conversations have also leapt to the fore.

At the same time that we’re learning about essential and non-essential work, maybe the bells ringing, kids chirping, and birds singing are the essential sounds that were getting lost in the shuffle before.

The second way that my home has changed is how it’s turned in on itself. What’s most familiar to me (my routines and “home-work”) have had to turn their backs, even more than usual, on everything that’s happening “outside.” It seems to me that you can view “sheltering in place” as either being banished from the wider world and losing what it has to offer or as finding a refuge and gaining something you didn’t have before. When the public world becomes a threatening reality, it almost invites you to see whether your private world can provide new sources of comfort: balms and salves that might always have been there but that you’d failed to notice.

I’d recently read that the best workshop (or kitchen or closet) is the one where you can see everything that you need to fix (or cook or wear). The advice was less Marie Kondo and more Yankee practicality, arguing that nothing that you need should ever be buried behind something else and effectively “unavailable.” In other words, the necessary tools and ingredients should always be visible and within easy reach so that they’re “on hand” when you’re ready for them.

Being a tourist in today’s strangeness has enabled me to see the necessities that had been buried in clutter until now and to identify the gaps in needed supplies that I still have to fill. With fresh eyes, I’ve been enabling a kind of preparedness when it comes to day-to-day living whose beauty had escaped me until now and (ironically) that also seems to have escaped many of our leaders as we face a respiratory pandemic without enough ventilators, protective equipment, test kits, hospital beds or medical staff “on hand” while being awash in almost everything that’s non-essential.

The sudden contrast between my public and private worlds has fostered another tourist-like appreciation too. The daily horror of a virus approaching from all directions along with our near helplessness to fend it off puts into bold relief the promise of spring that’s unfolding without any human assistance at all. With different eyes, daily miracles in the trees and on the ground that used to go unnoticed provide me with a deeper hope than even the acts of selfless heroes that life (although not as we’ve known it) will go on.

When the old, familiar world tries to return and the strangeness of the present one recedes, there will be blame enough for this to go around. The question, I suppose, is whether we all bear some of that responsibility and should get on to something that’s far more useful than finger pointing—starting right now.

As we shelter-in-place and social distance, there is another discrepancy between our old and new worlds that provides the ground for those insights. It is how much the familiar world that we used to know has slowed itself down.

There is nowhere to rush to in coming weeks and months; in a very real sense, many of us are already there. Aside from emergency medical and safety net workers, most of us have less paying work if we have any at all, which gives the days a molasses-like quality, concentrating and reserving some of our energy for later on, when it will be sorely needed to rebuild. Even with kids home from school and close quarters, we can still bring the curiosity of tourists to the slow task of contemplating how we’ll need to change our priorities if we’re to thrive and prosper in the next world.

There are easy fixes, like resolving to pay more for local workers (instead of factories overseas) to make essential supplies and then stockpiling these critical reserves. But there are more basic questions about what is, or should be, essential. If China, where the virus started, in fact suffers ten thousand deaths from this plague and America suffers a hundred or two hundred thousand, what does that say about our priorities and way of life and how we might change them going forward? In a democracy like ours, in all democracies, it is for us to decide on what we need most and how our free markets, awesome technologies and representative governments should manage our scarce resources to meet those needs.

Like foreign travel, a shared calamity like this one makes us curious about all manner of things we never seemed to notice when we trusted the familiarity of our old lives and work. Like travel, this virus and our responses to it have torn the blanket off, revealing facets of the ordinary we may have taken for granted while also forcing basic questions about how to move forward more effectively given the lessons we’re learning.

Because we’ve noticed the life force and inventiveness that some of our governors, nearly all of our essential workers, and many DIY by-standers have brought to this calamity, it’s only fair to ask whether we can find ways to harness their extraordinary energies to the energy we’ve been storing so we can build a society that can do a better job of sustaining us than the familiar one we’ve been seeing these last few weeks with different eyes?

Do we have, in Heneghan’s memorable phrase, enough of the tourist’s “other wonder” to imagine and then build a new world on this energetic foundation now that some of the fatal flaws of the world we’re leaving behind have been exposed?

Other-wonder may be this calamity’s greatest gift. It would be a terrible shame to waste it whenever it arises during these suddenly quiet and slow days that—like the newly planted tree above—promise each of us so much.

Stay safe and in the game. I’ll see you next Sunday.

Now into the second month of this coronavirus, I’ve kept the weekly newsletter format here (from my April 5, 2020 newsletter) instead of adapting it for this post. Newsletters are delivered to subscribers’ in-boxes every Sunday morning and the contents of some of them later appear here. If you’d like to receive a weekly newsletter, you can subscribe by leaving your email address in the column to the right.

When we change our routines in a fundamental way—either because we need that change or the interruption is foisted upon us—we sometimes experience our world differently when we return.

Glimpses of those differences are possible after vacations, but they usually need to be long enough and far enough away. These differences in perspective also need to become realizations: our conscious efforts “to capture” what our time away “was really about” and consider its impacts “on what we do next.” At this point, the contrast between before and after might be bold enough to change our outlook going forward—like eat more pasta or dance everyday—but these realizations seldom change the basics about our living, our working or how we think about them. They’re more like souvenirs.

Clearer and longer breaks between departure and return generally have a greater impact because there’s more time to ponder the differences between this new place and the one we left behind. When we return to where we started, we are able to compare how it seemed before with how it seems to us now in light of the new perspectives that we’ve gained. As a result of these realizations, we sometimes do change our basic routines or broaden our rationales for doing them.

Insights about what-came-before, what-came-next and now-that-you’re-back can be even more profound if your physical or mental abilities changed during this interval. For example, you needed a new environment because you were injured in some way or found yourself facing an unfamiliar limitation. Only after time-away were you healed enough to return to the world you had left behind. Your judgments can be more nuanced when the changes to your body or spirit have also sharpened your awareness of where you’ve been and where you find yourself now.

Insights about before, next and now might be sharper still if changes in your perceptual abilities were behind your initial departure. If, say, you’d been partially blinded and had to rely on the heightened senses that remained to “map” the new environment where you retreated and the old one that you returned to “with new eyes.”

Finally, your insights might be at their sharpest and most valuable if the world you left had also changed in some fundamental way in the months or years before your return. The heightened awareness that you gained while away would be encountering this new topography for the first time. It is this final vantage point that Howard Axelrod brings to his new book, The Stars in Our Pockets: Getting Lost and Sometimes Found in the Digital Age.

Axelrod’s short story is that he was accidentally blinded in one eye during a college basketball game, took the next 5 years to graduate and recover physically, and spent the two years that followed living off the grid and reorienting himself with his natural environment in the woods of northeastern Vermont. After his time away, he began a teaching career at two urban universities.

Between his partial loss of sight and his return to civilization, smartphones had not only become ubiquitous, but in startling contrast to his back-woods life, these “stars in our pockets” seemed to be changing “how we navigated the world” right in front of him. It was an insight that might not have been possible if the contrasts between the world he’d departed, the one he retreated to and the one he re-entered had been less stark, or the realizations that he took from his experiences had been less acute.

In the “cognitive environment” of northern Vermont, Axelrod deepened his sense perceptions, made lucky discoveries as he wandered in the outdoors, and cultivated a sense of curiosity and patience that had been commonplace for much of human history. He learned to pay attention to the weather, the seasonal changes, the time of day, the life of the forest around him, and realized that doing so reinforced a particular kind of “mental map” that enabled his understanding of the world and how he could find his way through it. When Axelrod returned to urban life, he realized that the smartphones people were now holding as they walked down the street or sat across from one another at lunch were changing how almost everyone—including him—understood and experienced the world. In other words, the mental map that a smartphone enables is fundamentally different from the mental map he’d been using to navigate during his time off the grid.

The message in Axelrod’s book is not that one map is better than the other. His writing is more “meditation” (as he calls it) than argument or indictment. Instead, he wants to highlight some of the complications that can arise when you alternate between how humans have always navigated their lives and work and the new ways of doing so that mediating devices like our smartphones have enabled. In a recent interview and from postings on his website, Axelrod wants to convey what happens when adapting to a new environment means “losing traits that you valued” in your first one.

Just as we’re losing diversity of plant and animal species due to the environmental crisis, so too are we losing the diversity and range of our minds due to changes in our cognitive environment.

Several of these losses are worth our noticing with him. For example,:

–Tech tools may replace natural aptitudes and weaken the memories that they depend upon. Axelrod suggests that relying on GPS to navigate undermines not only the serendipity that often comes “when you’re finding your own way,” but also your reliance on innate navigational memories so that you don’t get lost. Axelrod says:

Our memory is tied inextricably to place. In our brains, the memory center, the hippocampus, is the same center for cognitive mapping — figuring out the route you’re going to take. If we’re no longer using our brains to navigate [and] coming up with these cognitive maps, studies show that we start to have problems with other kinds of memory.

–External prompts change our attention spans. As we grow more accustomed to on-line suggestions before taking the next step, autonomous actions—including immersing yourself in an activity and entering into what psychologists call productive “flow states”—become more difficult.

What [American philosopher William] James [once] said is that an attention span is made of curiosity. It’s the ability to ask subtly different questions. Whether you’re talking about intellectual attention, or sensorial attention, if you’re looking at a tree or watching a bird. Are you asking subtly different questions? Can you ask a question about one facet and then another? It feels like you’re paying attention steadily, but you’re really paying attention to a lot of different things, driven by your curiosity.

Online, there’s always something prompting your attention. It’s like a pseudo-curiosity. It comes in and will give you the next thing to purchase, the next article to read, the next video clip to watch. You don’t have to ask the next question — it’s provided for you. Your attention span will shorten because you don’t need to ask those questions, you don’t need to drive your own attention.

–Rapid-fire “likes” on-line also requires much less involvement from us than empathy requires off-line. Axelrod notes how disorienting it can be as we shuttle between our tech-enabled environments and the rest of our lives and work, where we often need to come to what he describes as “slower” understandings of one another:

[W]hen you’re on social media, part of what’s being called for is attention that can shift really rapidly from one post to another post. And also what’s being called for is a kind of judgment: Do you like this? Do you love this? Do you retweet this? Whereas in real life, what’s called for is a slower attention, where you’re able to listen, be patient while the person is pausing, thinking, not quite sure what they’re saying. And also what’s called for is to defer judgment, or not judge at all. To have empathy. Those are very different traits, depending on which environment you’re in.

–It is hard to reconcile or internalize the different, competing ways that we use to navigate our on-line and off-line realities. Moreover, the world we experience behind the screen can become a substitute for (or even replace) the frameworks that come from navigating in the off-line world. What we risk losing, says Axelrod, are:

our connection to something larger than ourselves, our sense of perspective, our sense of what came before us or what will come after, our sense of being a part of the natural world — that doesn’t really show up anywhere on the maps on our phones.

As we adapt to a virtual world, we’re often disoriented because its cognitive maps are so different and “we’re effectively living in two places at once.” But our adaptations change how our minds work too. In what Axelrod calls “neural Darwinism,” a kind of “natural selection” also happens “on both sides of your eyes” as we adapt to living and working through our screens. “[C]ertain populations of neurons get selected and their connections grow stronger, while others go the way of the dodo bird.” In other words, the faculties that we exercise on-line grow stronger, while those from the off-line world that we rely upon less frequently weaken from disuse.

These losses are tangible: Remembering how to navigate the world without on-line short-cuts. The longer attention spans that we need for concentration. The slower attention spans we need for empathy. Perspectives that extend from the past and into the future. Feelings that we are a part of the natural world.

Our smartphones and other virtual companions are changing our capabilities in each of these ways, but like that frog in water coming to a slow boil, too many of us may be lulled into complacency by the warmth of their star-power.

Axelrod returned from the Vermont woods when the rest of us were already caught up in their magic. With the heightened sense of being human that came from his own particular odyssey, he could see more clearly not only what we’d been gaining while he was away but also might be losing as we gradually moved off our old navigational maps and started our pell-mell quest to adapt to very different ones.

The map at the top of this post illustrates how navigation, weather, visibility, air pollution—a dozen different variables—might change in light of the fires that have recently burned through much of the western US. A poor attempt at metaphor (perhaps), but many of the fires on this map also originated in northern California, where many of the technologies behind our smartphones originated.

These “stars in our pockets” with their shortcuts, search engines and diversions are causing us to adapt to the navigational demands of an entirely new environment, where the potential costs of doing so include the loss of deep-seated memory, the ability to make our own choices, and discomfort with the “slow art” of interacting with others. Because we don’t exercise these aptitudes when navigating our new mental maps, we risk losing them as we attempt to navigate the old maps of our parallel, off-line worlds.

In a December post, I shared Tristan Harris’s theory that our brains may simply not be able to handle the challenges posed by these tech-driven interfaces. Harris went on to argue that the overwhelming information they provide also produces a kind of learned helplessness in us that’s not so different from where the frog, coming to a slow boil, finds herself.

The trick, I think, is making a deliberate effort to exercise the human capabilities that enabled us to navigate the world before these awesome devices came along—not letting them atrophy—even if we have to spend some equivalent of Howard Axelrod’s time in the northern Vermont woods to come to that realization.

We may need the sharpness, the clarity, of something like his departure and return to notice that much seems to be going awry before we resolve to do something about it.

This post was adapted from my February 2, 2020 newsletter. Newsletters are delivered to subscribers’ in-boxes every Sunday morning and the contents of some of them are later posted here. If you’d like to receive a weekly newsletter, you can subscribe by leaving your email address in the column to the right.

One way to get out of the box that’s dominated by our value judgments is to make an imaginative leap, like taking on the perspective of someone we admire, and trying to see a situation—it can be any situation where we’re already convinced of our righteousness—through their eyes.

Value choices fuel our strongest commitments, but the deep, subconscious motivations behind them can also close off disagreeable viewpoints before we’ve ever had an opportunity to consider them rationally. Once my moral intuitions are engaged, feeling like I’ve actually made up my mind is just that—a feeling.

It takes an effort to keep yourself open for long enough that your rational side can go to work. In fact, it’s probably fair to say that your mind is never truly open unless you’re consistently making an effort to stay open-minded.

Trying on a truly admirable perspective further improves your chances of broadening the moral framework that determines what you think, feel and end up doing about it.

Being Open-Minded Rarely “Just Happens”

First off, you have to decide that you really want to see old things in a new way, a suitable endeavor for any new year. It’s being willing to leave the garden of moral certainty that you’ve created for yourself behind—this gated community where everything that you believe feels grounded in Truth, while looking well-tended and -considered to everyone whose opinion matters.

Truly inhabiting another’s perspective takes repeated reminders to keep your doors and windows open. Trust me, without these markers it’s easy to lose track of your ambition and get “bogged back down” in the prejudices you are trying to escape.

A nagging suspicion that your certainties no longer explain every corner of the world you’re experiencing is a catalyst too.

It also helps when you are opening yourself to the perspective of someone you already acknowledge as a moral leader, even though you suspect you might disagree with some (or even a great deal) of what he or she stands for.

In short, the promise of growth through openmindedness requires your will as well as your imagination. You have to be dubious enough about your own moral certainties and willing enough to see the world through, say, Martin Luther King’s eyes, that you’ll actually make the effort to do so.

Yes. My suggestion today, on this day before we honor him, is to try to see your judgments and convictions about life and work through Martin Luther King’s eyes.

But First, a Brief Look At Some of What MLK Stood For

Most who were alive when Martin Luther King was assassinated are now more than 30 years older than King was when he died. They remember him with teenage and grade-school memories because few who are alive today ever reached mature judgments about him while he walked among them.

As a result, in the years since his assassination in 1968, MLK has often been appropriated by those who have attempted to pour his life or words into what they stand for instead of what he did. Taking heroic figures from the past and making them serve current agendas often distorts their legacies. For example, while MLK spoke passionately about the white racism that held his people down, he also spoke about anti-social behavior in poor black communities, telling a black congregation in St. Louis that “we’ve got to do something about our moral standards” as well.

We know that there are many things wrong in the white world, but there are many things wrong in the black world too. We can’t keep on blaming the white man. There are things we must do for ourselves.

He repeatedly urged his young followers to assume responsibility for their actions despite the racial barriers they confronted. While not always succeeding, King always tried to be “color-blind” by holding every combatant in the struggle for civil rights accountable for what they said and did. He was also convinced that everyone–black and white–shared a basic decency, even when their words and deeds suggested otherwise.

This is why one black commentator lamented the divisive way in which at least some of King’s legacy is being distorted today:

A generation of blacks who have more opportunity than any previous generation are being taught that America offers them little more than trigger-happy cops, bigoted teachers and biased employers. It’s not only incorrect, but as King and a previous generation of black leaders understood, also unhelpful.

Why unhelpful? Because it denies that MLK saw “a unity among people” that goes deeper than their actions and provides the ground for hope that’s essential to problem-solving and reconciliation.

Another part of King’s legacy—and one that the passage of time has been less able to distort—is the power and eloquence of his conviction that better days are coming.

Martin Luther King (like Lincoln and Churchill before him) understood that people need to be stirred to appropriate action during times of upheaval. As much as anything, it was his beautiful words, beautifully delivered, that drove the Civil Rights Movement and continue to inspire us today. It’s a rare feat when you’re able to carry the hopes of a crowd or a nation on the shoulders of your words.

Another thing is also true of great leaders like MLK. It is never just about how to resist your personal fears or hostile forces that are beyond your control. It is also about how you and your opponents can recover so that you’ll both be strong enough to confront the aftershocks of your discord together.

While MLK never stopped challenging injustice, he also never waivered in his vision of a better America at the other end—a hope that he struggled mightily to personify. We remember his resistance today, but what we sometimes forget was his ability to balance his challenge to racial injustice with a restorative view of the future. For him, the anguish of non-violent protest and the hostility it unleashed were almost always relieved by his belief in human decency and our ability to overcome what divides us. It’s the dream that sustained him as he marched doggedly forward.

Martin Luther King’s charge that we should always face what’s coming “now,” “next” and “ultimately” reminds us of Lincoln during the slog of the Civil War and Churchill through the long nights when England was bombed during World War II. It was his ability to affirm our basic decency and resilience at each stage of his resistance that can continue to rally us today.

A Stirring Proposal

To get out of our moral comfort zones, the proposal is to try-on MLK’s perspective. As in these pictures from the sidewalks of NYC’s Upper East Side, the recommendation is for purposeful wandering beyond the confines of the tidy borders and careful gardens that our value judgments have arranged for us. In other words, you become (for awhile) the dogs and dog walkers in this scenario, sniffing around the edges of what we believe and finding out whether we can be more open to those who disagree with our views about what is right and true.

Trying on Martin Luther King’s perspective wasn’t my idea. It comes from Cornel West and Robert George, both at Princeton, where West teaches something called “the practice of public philosophy” and George teaches jurisprudence. In a “Houses of Worship” column of the Wall Street Journal, they wrote as follows:

One of us invokes “the radical King” in criticizing empire, capitalism, and white supremacy. The other recalls King’s principles in defending the unborn, Down syndrome and other disabled people, the frail elderly, and every life…

[Because of the range and depth of his views], in judging and acting, we must avoid sinning against King’s legacy by facilely claiming him for whatever policies we favor. A more fitting attitude, one consistent with what was truly radical about King, is to imagine him as a critic: “If Martin Luther King would be on the other side of where I happen to be on this question—why?”

This self-critical stance honors King by recognizing the centrality of his Christian faith to his work and witness…

King was truly radical in his literal reading of Jesus’ command that we love others unconditionally, selflessly and self-sacrificially. And by “others,” he meant everyone—even those who defend injustice. He believed in struggling hard, and with conviction, for what one believes is right; but he equally insisted on seeing others as precious brothers and sisters, even if one judges them to be gravely in error…

King saw himself as the leader of a love-inspired movement, not a tribe or “identity group,” and that is because his radical love ethic refused to divide people into tribes and identity groups.

You can read the West-George piece here. I also propose, with its authors, that you put MLK inside your head and imagine that he’s your interlocutor.

“If Martin Luther King would be on the other side of where I happen to be on this question—why?”

You might be surprised where this act of the imagination takes you, and how quickly the moral barriers between you and those you disagree with so fervently might start to come down.

More of King’s Words

What made me write about King today was seeing a new documentary about the days in Memphis before his assassination, hearing part of his last speech at the Mason Temple on April 3, 1968, and then sitting in one place and listening to everything he said that night, from start to finish.

It’s a long speech, almost 45 minutes, but the singles, doubles and triples he sends into the choir with that sonorous voice—like “if only he’d sneezed,” so close was the knife when someone tried to kill him once before—issue forth with a kind of inevitability until his final grand slam and onto that fateful next day. It’s magnificent.

And here’s why. Not only does it consistently bridge his now, his next and his ultimately with what he calls “a dangerous unselfishness,” it also demonstrates how much Martin Luther King was living his own words.

Little was going well for King in Memphis that week. There were constant death threats against him and it must have been unsettling for him to even go out his door every morning. It wasn’t just the courage that it took to march on the City’s mean streets, he also had to look brave when he knew that he might be dead by the end of the day. It was the oppressiveness of his mortality that elevated his last words—how he embodied it and then rose above it, right before the eyes of those who had come to see him.

If you want another reason to let Martin Luther King act as a voice in your head, listen to this speech. It’s a privilege to be in the same room with him just hours before he died, hearing him live the words that hitched his own fears to a sturdier promise.

A Walk Outside The Lines

The pictures above convey the wonderful orderliness of my moral perspectives too. What’s right and what’s wrong for me is always so certain, arranged and impervious to the lifted leg of anyone who falls outside of it.

I’m for this, so I also against that and that and that: all neat and comfortable and predictable. But isn’t life messier and more interesting than that?

My self-esteem depends on projecting the best moral viewpoint I can come up with so I can be proud of what I stand for and admired by my fellow believers for our shared truths. But doesn’t our self-esteem become ossified and brittle when we keep it in such tidy containers?

On this or this or that, how might MLK see “what I’m so sure about” quite differently than I do?

This post was adapted from one I wrote two years ago but wished, at the time, I had posted closer to Martin Luther King Day when this great man is already on our minds. In addition because I was so challenged by Cornel West’s and Robert George’s suggestion, I wrote about another one of their efforts to find unity despite our deepest disagreements last February. Here’s a link to it.

A newsletter that included this post was sent to subscribers on January 19, 2020. Newsletters go out every Sunday morning and, from time to time, I post the content here as well. If you want to subscribe to my weekly newsletter, please provide your email address in the column to the right.

Since recent posts here and here about work in healthcare—discussing burnout among health professionals, concerns about misuse of patient data, and questions about who is policing our rapidly changing health system—I’ve continued to follow developments in the field.

Over the past few weeks, some of you have also shared your troubled reactions about how work in healthcare has been evolving.

The net of these developments is that while there are grounds for alarm about the uses of our health data, its proliferation presents some extraordinary opportunities too. Concepts like “precision medicine” become more realistic as the amount and quality of the data improves. More and better data will also help us to live longer and healthier lives. On the other hand, whether AI and other data-related technologies can enable us to improve the quality of the work experience for millions of healthcare professionals is a stubbornly open question.

In this last healthcare-related post for a while, there are two, practical rules of thumb that might give us greater sense of control over how our healthcare data is being used, as well as a couple of ways in which more and better health-related information is already producing better patient outcomes.

The good work of getting the healthcare that we need as patients (both for ourselves and for others that we’re caring for) requires healthy doses of optimism as well as pessimism, together with understanding as much as we can about when excitement or alarm are warranted.

Two Rules of Thumb To Inhibit Misuse of Our Medical Data

The first rule of thumb involves insisting upon as much transparency as possible around the uses of our medical information. That includes knowing who is using it (beyond the healthcare provider) and minimizing the risks of anyone’s misuse of it.

Unfortunately, more of this burden falls on patients today. As health systems increasingly look to their bottom lines, they may be less incentivized to protect our personal data streams. And even when our interests are aligned, doctors and hospitals may not be able to protect our data adequately. As I wondered here a couple of weeks ago: “Can these providers ‘master the learning curve’ [of big data-related technologies] quickly enough to prevent sophisticated consultants like Google from exploiting us, or will the fox effectively be running the chicken coop going forward?”

An article last weekend in the Wall Street Journal called “Your Medical Data Isn’t As Safe As You Think It Is” raised a couple of additional issues. As patients, we may be lulled into complacency by the fact that much of our data is rendered “anonymous” (or stripped of our personal identifiers) before it is shared in big databases. But as this article describes at length, “de-identified” data in the hands of one of the tech companies can easily be “triangulated” with other data they already have on you to track your medical information back to you. That means they remain able to target you personally in ways you can imagine and some you cannot.

Moreover, even if it remains anonymous, your medical data “in a stranger’s hands” may still come back to haunt you. As one expert in data sharing observed, companies that monetize personal data currently provide very little information about their operations. That means we know some of the risks to us but are in the dark about others. Of the known risks around data dispersal, you may suddenly find yourself paying higher health-related insurance premiums or barred from obtaining any coverage at all:

Google will be in a good position to start selling actuarial tables to insurance companies—like predictions on when a white male in his 40s with certain characteristics might be likely to get sick and expensive. When it comes to life and disability insurance, antidiscrimination laws are weak, he says. ‘That’s what creates the risk of having one entity having a really godlike view of you as a person that can use it against you in ways you wouldn’t even know.’

Our first rule of thumb as customers in the health system is to insist upon transparency around how our providers are sharing our medical information, along with the right to prevent it from being shared if we are concerned about how it is will be used or who will be using it.

The second rule of thumb has always existed in healthcare, but may be more important now than ever. You should always be asking: is my medical information going to be used in a way that’s good for me? If it’s being used solely to maximize Google’s revenues, the answer is clearly “No.” But if your information is headed for a health researcher’s big data set, you should ask some additional questions: “Was someone like me considered as the study was being constructed so the study’s results are likely to be relevant to me?” “Will I be updated on the findings so my ongoing treatment can benefit from them?” (More questions about informed consent before sharing your medical data were set forth in another article this past week.)

Of course, understanding “the benefits to you beforehand” can also help you determine whether a test, drug or treatment program is really necessary, that is, if it’s possible to assess the pros and cons with your doctor in the limited time that you have before he or she orders it.

With medical practitioners becoming profit (or loss) centers for health systems that operate more like businesses, the good work of protecting yourself and your loved ones from misuse of your data requires both attention and vigilance at a time when you’re likely to be pre-occupied by a range of other issues.

More and Better Data Is a Cause for Excitement Too

There is an outfit called Singularity University that holds an annual conference each year with speakers who discuss recent innovations in a range of fields. Its staff also posts weekly about the most exciting developments in technology on a platform called Singularity Hub. One of its recent posts and one of the speakers at its conference in September highlight why more and better medical data is also a cause for excitement.

To understand the promise of today’s medical data gathering, it helps to recall what medical information looked like until very recently. Most patient information stayed in medical offices and was never shared with anyone. When groups of patients were studied, the research results varied widely in quality and were not always reconciled with similar patient studies. Medicine advanced through peer reviewed papers and debates over relatively small datasets in scholarly journals. Big data is upending that system today.

For us as patients, the most exciting development is that more high quality data will give us greater control over our own health and longevity. This plays out in (at least) two ways.

In the first instance, big data will give each of us “better baselines” than we have today about our current health and future prospects. According to the Singularity Hubpost, companies as well as government agencies are already involved in large-scale projects to:

measure baseline physiological factors from thousands of people of different ages, races, genders, and socio-economic backgrounds. The goal is to slowly build a database that paints a comprehensive picture of what a healthy person looks like for a given demographic…These baselines can then be used to develop more personalized treatments, based on a particular patient.

Although it sounds like science fiction, the goal is essentially “to build a digital twin of every patient,” using it in simulations to optimize diagnoses, prevention and treatments. It is one way in which we will have personalized treatment plans that are grounded in far more accurate baseline information than has ever been available before.

The second breakthrough will involve changes in what we measure, moving organized medicine from treatment of our illnesses to avoidance of most illnesses altogether and the greater longevity that comes with improved health. As these developments play out, it could become commonplace for more of us to live well beyond a hundred years.

At Singularity University’s conference two months ago, Dr. David Karow spoke about the data we should be collecting today to treat a broad spectrum of medical problems in their early stages and increase our life expectancy. He argues that his start-up, Human Longevity Inc., has a role to play in that future.

Four years ago, Karow conducted a trial involving nearly 1,200 presumably healthy individuals. In the course of giving them comprehensive medical checkups, he utilized several cutting edge diagnostic technologies. These included whole-genome and microbiome sequencing, various biochemical measurements and advanced imaging. By analyzing the data, his team found a surprisingly large number of early stage tumors, brain aneurysims, and heart disease that could be treated before they produced any lasting consequences. In another 14% of the trial participants, significant, previously undetected conditions that required immediate treatment were discovered.

Karow’s argument is that we’re “not measuring what matters” today and that we should be “hacking longevity” with more pre-sympomatic diagnoses. For example, if testing indicates that you have the risk factors for developing dementia, you can minimize at least some of those risks now “because of third of the risks are modifiable.”

Every start up company needs its evangelists and Karow is selling “a fountain of youth” that “starts with a fountain of data.” This kind of personal data gathering is expensive today and not widely available but it gestures towards a future where these sorts of “deep testing” may be far more affordable and commonplace.

We need these promises of more personalized and preventative medicine—the hope of a better future—to have the stamina to confront the current risks of our medical data being monetized and misused long before we ever get there. As with so many other things, we need to hold optimism in one hand, pessimism in the other, and the ability to shuttle between them.

This post was adapted from my December 1, 2019 newsletter. When you subscribe, a new newsletter/post will be delivered to your inbox every Sunday morning.

After writing about the growing challenges and responsibilities facing medical professionals and patients last week, I happened upon two posts about the burnout rates for the professionals who are charged with promoting health and healing in the rest of us.

The first was a PBS Newshour segment about the extent of the problem and, more recently, some possible cures. It cited studies from recent years that doctors commit suicide at twice the rate of the general population, that 86 percent of the nurses at one hospital met the criteria for burnout syndrome, that 22 percent had symptoms for post-traumatic stress disorder, and that the PTSD numbers for critical care nurses were comparable to those of war veterans returning from Afghanistan and Iraq. The reporter described what is happening as “a public health crisis.” In a small ray of hope, providers have also begun to create outlets—like arts programs—so healthcare workers can “process some of the trauma” they are experiencing on a daily basis and begin to recover.

The second post, in Fast Company, discussed the most stressful jobs that are being done by women today, including the category “nurses, psychiatric healthcare provides and home health aides.” It noted that registered nurses are 14-16% more likely to have poor cardiovascular health than the rest of the workforce, “a surprising result” because the job is so physically active and nurses are more knowledgeable about the risk factors for cardiovascular disease than the workforce in general.

Several of you who work in the health care industry wrote to me this week about your experiences at work, which (sadly) mirror these discouraging reports.

The other follow-up development relates to the data that is being gathered from patients by the health care industry. Earlier this week, the Wall Street Journalreported hat Google had struck “a secret deal” with Ascension, one of the nation’s largest hospital systems, to gather and analyze patient data including lab results, doctor diagnoses and hospital records. Called Project Nightingale by Google and “Project Nightmare” by others, the data extraction and analysis “amounts to a complete health history, including patient names and dates of birth.” Having all of our medical information instantly available for analysis in one place is clearly a game changer.

The first alarm bells sounded about Project Nightingale involved the privacy of patient data. (Indeed, the day after its initial report, the Journal reported that the government had launched an investigation into Google’s medical data gathering on the basis of these concerns.) Among the privacy-related questions: will access to a patient’s data be restricted to practitioners who are involved in improving that patient’s outcomes? If this data can be used by others, how will it be used and how is the hospital system ensuring that those uses are consistent with that provider’s privacy policies? The governing statute, the Health Insurance Portability and Accountability Act of 1996, provides only the loosest of restrictions today. (Hospitals can share data with business partners without telling patients as long as the information is used “only to help the covered entity carry out its health care functions.”)

On the positive side, the aggregation of patient data can facilitate more accurate diagnoses and more effective patient treatment.

Google in this case is using the data in part to design new software, underpinned by advanced artificial intelligence and machine learning that zeroes in on individual patients to suggest changes to their care.

More troubling, given Medicine’s continued drift from “profession” to “business,” is how providers can realize more profits from their patients by prescribing more medications, tests and procedures. How can patients distinguish between what they truly need to promote their healing and what is profit-making by the health care provider? As the Journal story also reports:

Ascension, the second-largest health system in the U.S., aims in part to improve patient care. It also hopes to mine data to identify additional tests that could be necessary or other ways in which the system could generate more revenue from patients, documents show.

How will patients be protected from unnecessary interventions and expense, or, unlike today, be enabled by industry reporting about medical outcomes to protect themselves? As I argued last week, the ethical responsibilities for everyone in healthcare–including for patients–are shifting in real time.

Earlier this year, I posted (here, here and here) on a similar Google initiative regarding smart cities. In places like Toronto, the company is helping government to gather and “crunch” data that will allow their cities to operate “smarter” and provide greater benefits for their citizens from the efficiencies that are achieved. As with Project Nightingale, there are privacy concerns that Google is attempting to address. But there are also key differences between this tech giant’s plans for monetizing citizen data in smart cities and its plans for monetizing patient data in the medical system.

In healthcare, your most personal information is being taken and used. This data is far more vital to your personal integrity and survival than information about your local traffic patterns or energy usage.

Moreover, in smart cities there are governments and long-established regulatory bodies that can channel citizen concerns back to government and its tech consultants, like Google. Because these interfaces are largely absent in health care, monitoring and enforcement is up to individual patients or hospital-sponsored patients’ rights committees. In other words, if you (as a patient) aren’t “watching the store,” almost no one will be doing so on your behalf.

To this sort of concern, Google responds both early and often, “Trust us. We’ve got your interests at heart,” but there are many reasons to be skeptical. Another Fast Companyarticle that was posted yesterday documented (with a series of links) some of Google’s recent history mishandling user data.

Google has gotten in trouble with European lawmakers for failing to disclose how it collects data and U.S. regulators for sucking up information on children and then advertising to them. The company has exposed the data of some 52 million users thanks to a bug in its Google+ API, a platform that has been shutdown. Even in the field of health, it has already made missteps. In 2017, the U.K.’s Information Commissioner’s Office found the way patient data was shared between the Royal Free Hospital of London and [Google affiliate] DeepMind for a health project to be unlawful. The app involved…has since controversially been moved under the Google Health umbrella. More recently, a lawsuit accused Google, the University of Chicago Medical Center, and the University of Chicago of gross misconduct in handling patient records.

Much of moving forward here depends on trust.

Will health care providers, that suddenly have the profit-making potential of big data, protect us as patients or see us only as revenue generators?

Can these providers “master the learning curve” quickly enough to prevent sophisticated consultants like Google from exploiting us, or will the fox effectively be running the chicken coop going forward?

What will Google and the other data-gatherers do to recover trust that seems to be damaged almost daily wherever their revenues depend upon selling our data to advertisers and others who want to influence us?

Is Google’s business model simply incompatible with the business model that is evolving today in health care?

As the future of medicine gets debated, we all have a say in the matter.

This post was adapted from my November 17, 2019 newsletter. When you subscribe, a new newsletter/post will be delivered to your inbox every Sunday morning.